Extra joint stabilization construct

ABSTRACT

The disclosure provides devices and methods of use pertaining to extra joint stabilization. Embodiments include a number of suture returning and locking anchors that feature both a suture return element and a suture locking feature that employs an interference fit between a flexible synthetic strand, a receiver of the anchor, and a set screw, where the receiver and the set screw each have a number of gradual, opposing tapers to facilitate gradual proximal-to-distal gripping and releasing of the flexible strand to achieve an optimal locking force while preventing severing of the flexible strand. Embodiments also include a counter-torque anchor driver configured to resist torsional forces generated during and translated to the anchor during set-screw insertion. Further embodiments include extra joint reinforcement, stabilization, and attachment constructs formed using the disclosed devices. Other embodiments are disclosed.

REFERENCE TO PENDING PRIOR PATENT APPLICATIONS

This application claims the benefit under 35 U.S.C. 119(e) of U.S.Provisional Patent Application Nos. 62/358,231, filed Jul. 5, 2016 byJustin Taber and T. Wade Fallin for “LIGAMENT REINFORCEMENT DEVICES ANDMETHODS,” 62/425,560 filed Nov. 22, 2016 by Justin Tabor, PhinitPhisitkul, and T. Wade Fallin for “LIGAMENT REINFORCEMENT DEVICES ANDMETHODS,” 62/456,217, filed Feb. 8, 2017 by Justin Taber and T. WadeFallin for “PLATE AND LOOP CONSTRUCT,” and 62/458,975, filed Feb. 14,2017 by Matthew Karam, Phinit Phisitkul, Justin Taber, and T. WadeFallin for “PELVIC FRACTURE REPAIR,” all of which patent applicationsare hereby incorporated herein by reference.

REFERENCE TO CO-FILED APPLICATIONS

This application was co-filed with the following U.S. Patent ApplicationNumbers on Jul. 5, 2017: Ser. No. 15/______ by Matthew Karam, PhinitPhisitkul, Justin Taber and T. Wade Fallin for “INTRA JOINTSTABILIZATION CONSTRUCT,” (Attorney Docket No. 81243.0001); Ser. No.15/______, by Justin Taber and T. Wade Fallin for “NONCIRCULAR BROACHAND METHODS OF USE,” (Attorney Docket No. 81243.0003); Ser. No.15/______, by Phinit Phisitkul, Justin Taber, and T. Wade Fallin for“MULTIPLE SUTURE THREADER AND METHOD OF USE,” (Attorney Docket No.81243.0004); and Ser. No. 15/______, by Justin Taber and T. Wade Fallinfor “COMPRESSION AND TENSION INSTRUMENTS AND METHODS OF USE TO REINFORCELIGAMENTS,” (Attorney Docket No. 81243.0005); all of which patentapplications are incorporated herein by reference.

BACKGROUND

Ligaments interconnect bones of the skeletal system and are involvedwith the stabilization and kinematics of skeletal joints. Variousinjuries may occur that result in compromised ligament function and/orbone fractures. Such injuries include, for example, partial and completetears and avulsion of the bone where a ligament attaches to a bone. Suchinjuries occur throughout the skeletal system.

By way of example, the human pelvis 2100 is a complex junction ofmultiple bones and soft tissues, as shown in FIG. 1. The sacrum 2102bounds the posterior aspect of the pelvis with a pair of hip bones 2104,2105 bounding the lateral and anterior aspects of the pelvis. Each hipbone is composed of three parts including the ilium 2106, 2107; ischium2108, 2109; and pubis 2110, 2111. The sacrum is joined to each hip bone2104, 2105 by strong ligaments at the sacroiliac joint 2112, 2113. Thehip bones 2104, 2105 are joined anteriorly at the cartilaginous pubicsymphysis 2114.

Various conditions may cause the pelvis to become unstable. For example,childbirth and traumatic injury may result in instability at thesacroiliac joint 2112, 2113 and/or the pubic symphysis 2114. Forexample, a traumatic anterior-posterior compression fracture may resultin a separation 2116 between the hip bones at the pubic symphysis 2114,as shown in FIG. 1, and loosening of the sacroiliac joint 2112, 2113leading to pelvic instability.

In another example, the human ankle 100 is a complex junction ofmultiple bones and soft tissues, as shown in FIGS. 2-4. The ankleincludes joints between the tibia 102, fibula 104, and talus 106. Thejoint between the tibia 102 and fibula 104 is a syndesmosis or slightlymovable joint in which the bones are joined together by connectivetissue. The syndesmosis between the tibia and fibula includes theanterior inferior tibiofibular ligament (AITFL) 110, the posteriorinferior tibiofibular ligament (PITFL) 112, and the interosseousligament (IOL) 114 (FIG. 4). The syndesmosis ligaments are often injuredin high ankle sprains. Other injury prone ligaments of the ankle jointinclude, among others, the anterior talofibular ligament (ATFL) 120, theposterior talofibular ligament (PTFL) 122 and the deltoid ligamentcomplex 124 including superficial and deep deltoid ligaments.

What is needed is improved implants, instruments and methods tostabilize bone fractures and/or reinforce ligaments.

SUMMARY

This Summary is provided to introduce a selection of concepts in asimplified form that are further described below in the DetailedDescription. This Summary is not intended to identify key aspects oressential aspects of the claimed subject matter. Moreover, this Summaryis not intended for use as an aid in determining the scope of theclaimed subject matter.

One embodiment provides a knotless returning and locking system for bonefracture stabilization and soft tissue repair and reinforcement. Thesystem comprises a returning and locking anchor having a body with aproximal end, a distal end, and defining a longitudinal axis, the bodyforming an internal passage and a return feature, the internal passagehaving a threaded receiver located at the proximal end of the body andincluding a proximal portion, a mid portion, and a distal portion, thereturn feature located distal to the threaded receiver and incommunication with the internal passage. The system also includes athreaded set screw having a proximal portion, a mid portion, and adistal portion, the threaded set screw configured for rotationalinsertion into the threaded receiver to achieve a progressivelyincreasing interference fit about a flexible synthetic strand passingbetween the proximal portions and the mid portions of the threadedreceiver and the threaded set screw and a progressively decreasinginterference fit about the flexible synthetic strand passing between themid portions and the distal portions of the threaded receiver and thethreaded set screw. The progressively increasing interference fit andthe progressively decreasing interference fit combine to provide alocking feature that reversibly secures the flexible synthetic strand inrelation to the returning and locking anchor.

Another embodiment provides a counter-torque driver for rotationallydriving an anchor into bone, the anchor having a proximal end, a distalend, and a driver feature, the driver feature comprising two opposingslots formed in the proximal end of the anchor. The counter-torquedriver comprises a longitudinal body extending from a proximal end to adistal end and defining a longitudinal axis, the longitudinal bodyincluding an axial through hole extending from the proximal end to thedistal end along the longitudinal axis. The counter-torque driver alsoincludes two opposing tabs extending from the distal end of the body,the two tabs centered about the longitudinal axis and configured toengage with the two opposing slots formed in the proximal end of theanchor. When the two opposing tabs of the driver are engaged with thetwo opposing slots of the anchor and the driver is rotated, the sutureanchor is rotationally driven into the bone. When the two opposing tabsof the driver are engaged with the two opposing slots of the anchor andthe driver is held stationary, each of the tabs provides a distal facingbearing surface to resist torsional forces generated when tensioning aflexible synthetic strand via a rotational input to a set screw insertedthrough the axial through hole of the driver into the anchor, therebycountering the torsional forces to maintain an original insertionalignment of the anchor within the bone.

Yet another embodiment provides an external construct for stabilizing ajoint. The construct comprises a flexible synthetic strand having firstand second opposing ends, a first fixation secured at the first end ofthe flexible synthetic strand, and a second fixation secured at thesecond end of the flexible synthetic strand. The second fixationcomprises a returning and locking anchor inserted into a bone portion,where the returning and locking anchor has a body with a proximal end, adistal end, and defines a longitudinal axis, and where the body forms aninternal passage having a threaded receiver located at the proximal endand a return feature located distal to the threaded receiver and incommunication with the internal passage, where (1) the second end of theflexible synthetic strand enters the returning and locking anchorthrough the axial passage at the proximal end of the body, routes aroundthe return feature, and exits the returning and locking anchor throughthe axial passage at the proximal end of the body; (2) the flexiblesynthetic strand is tensioned between the first and the secondfixations; and (3) the second end of the flexible synthetic strand islocked relative to the returning and locking anchor via a threaded setscrew that is rotationally inserted into the threaded receiver resultingin a continuous, uninterrupted length of the flexible synthetic strandextending externally across the joint between the first and the secondfixations.

Additional objects, advantages and novel features of the technology willbe set forth in part in the description which follows, and in part willbecome more apparent to those skilled in the art upon examination of thefollowing, or may be learned from practice of the technology.

BRIEF DESCRIPTION OF THE DRAWINGS

Non-limiting and non-exhaustive embodiments of the present invention,including the preferred embodiment, are described with reference to thefollowing figures, wherein like reference numerals refer to like partsthroughout the various views unless otherwise specified. Illustrativeembodiments of the invention are illustrated in the drawings, in which:

FIG. 1 illustrates an anterior view of a human pelvis having ananterior-posterior compression fracture;

FIG. 2 illustrates a right view of a human ankle joint;

FIG. 3 illustrates a front view of a human ankle joint;

FIG. 4 illustrates a rear view of a human ankle joint;

FIGS. 5-7 illustrate respective top, front, and cross-sectional views ofone embodiment of a returning and locking anchor;

FIG. 8 illustrates a cross-sectional view of a receiver of a suturelocking feature of the suture returning and locking anchor of FIGS. 5-7;

FIG. 9 illustrates a cross-sectional view of the receiver of FIG. 8having a set screw inserted therein to form an interference fit betweena suture and the receiver and the set screw;

FIG. 10 illustrates a front view of the set screw of FIG. 9 withoutthreading;

FIG. 11 illustrates the cross-sectional view of the set screw and thereceiver of FIG. 9, without threading;

FIGS. 12-14 illustrate respective exploded, front, and cross-sectionalviews of another embodiment of a suture returning and locking anchor;

FIGS. 15-18 illustrate respective side, perspective-exploded, andcross-sectional views of one embodiment of an anchor driver engagingwith the returning and locking anchor of FIGS. 5-7;

FIGS. 19-22 show partial sectional anterior views of the pelvis of FIG.1 and illustrate the steps of an operative sequence for stabilizing thecompression fracture of FIG. 1 using embodiments of the discloseddevices;

FIG. 23 provides a flowchart detailing the operative sequenceillustrated by FIGS. 19-22;

FIG. 24 illustrates exemplary reinforcement constructs for the deltoidligament complex and the posterior inferior tibiofibular ligament(PITFL)/anterior inferior tibiofibular ligament (AITFL) according toembodiments of the disclosed devices;

FIG. 25 illustrates one embodiment of a ligament reinforcement constructusing a single suture returning and locking anchor to reinforce twoseparate ligaments according to embodiments of the disclosed devices;and

FIG. 26 illustrates one embodiment of an attachment construct for softtissue repair or tendon reattachment according to embodiments of thedisclosed devices.

DETAILED DESCRIPTION

Embodiments are described more fully below in sufficient detail toenable those skilled in the art to practice the system and method.However, embodiments may be implemented in many different forms andshould not be construed as being limited to the embodiments set forthherein. The following detailed description is, therefore, not to betaken in a limiting sense.

The technology discussed herein relates to apparatus and correspondingmethods of use for preparing ligament reinforcement and bone fracturerepair constructs. Embodiments include a number of suture returning andlocking anchors, anchor drivers, and extra joint ligament reinforcementand/or bone fracture repair constructs constructed via operative methodsemploying the devices and instruments described herein.

Combined Suture Returning and Locking Anchors

FIGS. 5-7 illustrate top, front, and cross-sectional exploded views ofone embodiment of a suture returning and locking anchor 400. In FIGS.5-7, the anchor 400 includes an anchor body 402 having a proximal end404, a distal end 406, and defining a longitudinal axis 408. An externalbone thread 410 extends around most of the body 402 except proximallywhere the thread runs out distal to the proximal end, and distally wherethe thread runs out at a tapered tip 411. The bone thread 410 includes aself-tapping flute 412 at the distal end. A set screw 416 is configuredfor rotational insertion and locking within the proximal end 404, asdetailed further in relation to FIGS. 8-11 below.

The anchor 400 includes a suture return feature 413. In more detail andin this embodiment, the body 402 includes a first transverse hole 438forming opposed openings on opposite sides of the body 402 through whicha suture may be threaded to provide a suture return. While the externalbone thread 410 is engaged in a bone, a flexible synthetic strand suchas, for example, a suture, a suture tape, a cable or another suitableflexible synthetic strand (hereinafter a “flexible strand,” “flexiblesynthetic strand,” or “suture”) may be pulled against a proximal margin440 of the hole 438 to allow the suture to be tensioned. The bodyfurther includes an axial hole or passage 441 extending from an openingat the proximal end 404 toward the distal end 406. A second transversehole 444 extends through the body 402 to form opposed openings onopposite sides of the body 402. The second transverse hole 444 is offsetproximally from the first transverse hole 438 and communicates with theaxial hole 441.

In use, a suture may be threaded into the axial hole 441 from theproximal end 404, out one of the openings of the second transverse hole444, through the first transverse hole 438, in the other of the openingsof the second transverse hole 444, and out the axial hole 441 so thatthe suture is routed about the proximal margin 440 within the proximalportion of the body 402.

The anchor body 402 may further contain relief grooves 446 connectingthe openings of the first and second transverse holes 438, 444 on eachside of the body 402. The relief grooves 446 allow the suture to passfrom the axial hole 441 to the first transverse hole 438 whileprojecting less, or not at all, from the sides of the body 402 toprotect the suture from abrasion and to allow the suture to slide moreeasily while it is being routed and tensioned. In this embodiment, thebody 402 provides a tubular extension into a bone to protect the suturefrom abrasion from the bone as well as to protect the bone from abrasionor cutting from the suture.

The anchor 400 also includes a suture locking feature detailed in theexample of FIGS. 8-11. FIG. 8 provides an enlarged view of the internalfeatures of a proximal portion 403 of the body 402, and FIG. 9 providesa cross-sectional view of the proximal portion 403 of the body 402 inreceipt of the set screw 416. In this embodiment, the proximal portion403 of the body 402 includes a receiver 430 having a tapered receiverthread 432, and the set screw 416 has a tapered external thread 434.Both the receiver thread 432 and the set screw thread 434 are roundedknuckle threads. In addition, the receiver 430/receiver thread 432 andthe set screw 416/set screw thread 434 feature multiple discrete taperangles that transition proximally to distally to provide for progressivegripping and releasing of the suture 418 to provide a strong grip on thesuture while reducing the risk of suture damage or severing.

To address the taper angles in greater detail, FIGS. 10-11 illustratethe set screw 416 and the receiver 430 without their knuckle threadingto better illustrate the gradual transitions of their tapers. In thisembodiment, the set screw 416 is cylindrical at a proximal portion 450,has a relatively small angled taper over its mid portion 452, and has arelatively large angled taper over its distal portion 454 whichterminates in a rounded tip 464. The receiver 430 has a relatively largeangled taper at a proximal portion 456, has a relatively small angledtaper over its mid portion 458, and is cylindrical at its distal portion460. When the set screw 416 and the receiver 430 are mated, they provideprogressively less clearance between them from the proximal end of theanchor 400 to their mid portions and progressively more clearancebetween them from their mid portions distally to the end of the setscrew 416.

This opposing tapered configuration of the set screw 416 versus thereceiver 430 incorporates the principal of the Morse taper for matingcomponents. That is, the opposing conical shapes of the set screw 416and the receiver 430 are closely matched in angle at their mid portions452, 458, causing the respective surfaces of the set screw 416 and thereceiver 430 to achieve an interference fit about the suture 418 overthe mid portions 452, 458 of the set screw 416 and the receiver 430,with gradual transitions proximally leading into and distally leadingout of the interference fit. This gradual transition of compressionforces applied to the suture 418 disposed between the set screw 416 andthe receiver 430 leads to an enhancement in suture fixation/lockingstrength, and simultaneously reduces the risk of severing the suture 418that is present with greater magnitudes of compression force transition.

In one embodiment, the mid portions 452, 458 of the set screw 416 andthe receiver 430 are of the same length and aligned. In this embodiment,there are three zones or amounts of clearance between the set screw 416and the receiver 430 progressing in three steps from a relatively largeamount of clearance proximally to a relatively small amount of clearanceover their mid portions to a relatively large amount of clearancedistally.

Alternatively, and as shown in the example of FIGS. 8-11, the set screw416 can be driven so that the beginning of its mid portion 452 ispositioned distal of the beginning of the receiver mid portion 458, andthe end of the set screw mid portion 452 is positioned proximal of theend of the receiver mid portion 458, as shown in FIG. 11. Thisarrangement results in five clearance zones 440, 442, 444, 446, and 448for an even more gradual progression of gripping and releasing of thesuture 418. Any number of taper angle steps may be provided on the setscrew 416 and the receiver 430, and any arrangement of overlap or radiusblending may be provided to produce any number of progressive clearancesteps to transition proximally to distally from no grip to maximum gripto no grip on the suture 418, protecting the suture through the gradualincrease and decrease of stress placed on the suture 418.

Referring to FIG. 11, the first zone 440 provides the most clearanceproximally and the clearance decreases distally at the angulardifference between the cylindrical proximal portion 450 of the set screw416 and the relatively larger angle of the proximal portion 456 of thereceiver 430. The second zone 442 clearance decreases distally at theangular difference between the cylindrical proximal portion 450 of theset screw 416 and the relatively smaller angle of the mid portion 458 ofthe receiver 430. The third zone 444 provides the least clearance andcorresponds to where the mid portions 452, 458 of the set screw 416 andthe receiver 430 coincide. The fourth zone 446 clearance increasesdistally at the angular difference between the relatively smaller angleof the mid portion 458 of the receiver 430 and the relatively largerangle of the distal portion 454 of the set screw 316. The fifth zone 348provides the most clearance distally and the clearance increasesdistally at the angular difference between the relatively larger angleof the distal portion 454 of the set screw 316 and the cylindricalportion 460 of the receiver 330.

In the illustrative example of FIGS. 8-11, the set screw 416 taper iscylindrical in the first proximal portion 450, 10 degrees per side inthe second mid portion 452, and 20 degrees per side in the distalportion 454. The receiver 430 taper is 40 degrees per side in the firstproximal portion 456, 10 degrees per side in a second mid portion 458,and cylindrical at a third distal portion 460. The resulting relieftapers corresponding to the five zones 440, 442, 444, 446, 448illustrated in FIG. 11, proximally to distally, are 20 degrees, 10degrees, 0 degrees, 10 degrees, and 20 degrees. In this embodiment, theproximal ends 461, 463 of the receiver 430 and the set screw 416 arechamfered and the distal end 464 of the set screw 416 is rounded tofurther eliminate any sharp edges to further smooth the path of thesuture and to provide easier starting of the screw.

While the embodiment of the suture locking feature of FIGS. 8-11features opposing tapers on the set screw 416 and the receiver 430, itshould be understood that the invention contemplates any appropriatetapering configuration that provides a gradual increase and decrease ofcompression forces applied, proximally to distally, to the interferencefit of the suture 418 between the set screw 416 and the receiver 430.For example, the set screw 416 may be entirely cylindrical through itsproximal, mid, and distal portions, maintaining the above describedconfiguration of the receiver 430. In another example, the proximal,mid, and distal portions 450, 452, 454 of the set screw 416 may beangled to form an egg-like or football shape, while the proximal, mid,and distal portions 456, 458, 460 of the receiver 430 remaincylindrical.

The locking feature discussed in relation to FIGS. 8-11 provides both aknotless and reversible mechanism for locking out the suture 418relative to the returning and locking anchor 400. Because aninterference fit between the suture 418, the set screw 416, and thereceiver 430 provides the compression force required to secure thesuture 418 in tension relative to the anchor 400, the locking featureprovides a knotless fixation, thereby reducing the probability of boneand/or tissue abrasion and/or aggravation that is often caused byknotted fixations. Moreover, because the locking mechanism protects theintegrity of the suture through the gradual increase and decrease ofstress placed on the suture 418, discussed above, the knotless fixationis truly reversible in that the set screw 416 may be rotationallyinserted to lock out the suture 418 relative to the anchor 400 withoutdamaging the suture 418 and/or risking its structural integrity. As aresult, a surgeon may lock and unlock the suture 418 relative to theanchor 400 multiple times to achieve an optimal fixation whilemaintaining confidence in the quality of the ultimate knotless fixation.

The body 402 of the suture returning and locking anchor 400 furtherincludes a driver feature 458 in the form of opposing slots 462 (FIG.16) formed in the proximal wall of the body 402 for receiving an anchordriver such that the anchor driver does not block the receiver 430 fromreceiving the set screw 416 and for providing counter-torquestabilization such that a set screw driver does not axially shift thebody 402 during insertion of the set screw 416, as discussed furtherbelow in relation to 15-18.

FIGS. 12-14 illustrate exploded, front, and cross-sectional views ofanother example of a suture returning and locking anchor 500 that issimilar to the anchor 400. However, the anchor 500 of FIGS. 12-14 is atwo-piece anchor having an axial through-hole 541 that extends throughan entirety of a body 502 of the anchor 500.

In this embodiment, the anchor 500 includes the anchor body 502 having aproximal end 504, a distal end 506, and defining a longitudinal axis508. An external bone thread 510 extends around most of the body 502except proximally where the thread runs out. The bone thread 510includes a self-tapping flute 512 at the distal end. A set screw 516 isconfigured for rotational insertion and locking according to the lockingarrangement discussed above in relation to FIGS. 8-11.

The anchor 500 may provide a suture return function either internally orexternally. In an internal configuration, the anchor 500 may incorporatea removable suture return insert 550. The suture return insert 550includes a longitudinal body 552 centered about the longitudinal axis508 and sized to press fit within the axial hole 541 extending throughthe anchor body 502. The suture return insert 550 has a proximal end554, a closed distal end 556, and an axial hole or passage 558 extendingdistally from the proximal end 554. A first transverse hole 560 formsopposed openings on opposite sides of the insert body 552. The firsttransverse hole 560 communicates with the axial hole 558 of the insertbody 552 such that when the proximal end 554 of the insert 500 isinserted into the distal end 506 of the anchor body 502, the firsttransverse hole 560 within the insert body 552 aligns with a distalportion of a second transverse hole 538 within the anchor body 502 toform an internal suture return feature 513, as shown in FIG. 13, whichis similar to the return feature 413 discussed above in relation to theanchor 400 of FIGS. 5-7.

In use in the internal configuration, a suture may be threaded into theaxial hole 541 of the anchor 500 from the proximal end, out one of theopenings of the second transverse hole 538 in the anchor body 502,through the first transverse hole 560 in the insert 550, in the other ofthe openings of the second transverse hole 538, and out thecommunicating axial holes 441, 558 of the anchor body 402 and the insertbody 552 such that the suture is routed within the proximal portion ofthe anchor 500. The insert body 552 may further contain relief grooves562 connecting the openings of the first and second transverse holes560, 538 on each side of the anchor 500, when the insert 550 is disposedwithin the anchor body 502. The relief grooves 562 allow the suture topass from the axial holes 541, 558 to the first transverse hole 560while projecting less, or not at all, from the sides of the anchor body502 to protect the suture from abrasion and to allow the suture to slidemore easily while it is being routed and tensioned.

In an external configuration, the return insert 550 is excluded and thesuture return is formed by either the second transverse hole 538 or thedistal end 506 of the anchor body 502. In use in the external returnconfiguration, the suture enters the axial hole 541 at the proximal end504 of the anchor 500 and exits the axial hole 541 at either the secondtransverse hole 538 or the distal end of the anchor 500, with a returnsuture path outside the anchor body 502. In various embodiments, thereturn suture path passes through a notch or recess formed in the outerwall of the anchor body, through a relief groove in the bone thatprojects radially from the bone tunnel, as formed by, for example, thenoncircular punch and associated methods disclosed in FIGS. 2-10 of U.S.patent application Ser. No. 15/______ entitled “NONCIRCULAR BROACH ANDMETHODS OF USE” (Attorney Docket No. 81243.0003) and co-filed with thisapplication on Jul. 5, 2017, or in any other appropriate return path orrouting manner. Alternatively, the suture may exit the distal end 506 ofthe anchor and continue on a path directly to another fixation point(e.g., continue along the longitudinal axis 508, without a return,within a bone tunnel to another locking anchor).

Counter-Torque Anchor Driver

FIGS. 15-18 illustrate an example of an anchor driver 570 for use with,for example, the anchor 400 of FIGS. 5-7. The anchor driver includes anelongated body 572 extending from a proximal end 574 to a distal end 576and defining a longitudinal axis 578. The distal end 576 of the driverincludes opposed clearance slots 580, 582 opening distally and definingspaced apart driver legs 584, 586. The distal ends of the driver legs584, 586 form opposing tabs 588 that engage the opposed slots 462 of theanchor 400. The driver tabs 588 and driver slots 580, 582 are sized sothat with the tabs 588 fully engaged in the slots 462 of the anchor, thedriver slots 580, 582 provide clearance 592, 594 between the driver 570and the anchor 400 for the suture 418.

A portion of each tab 588 abuts the proximal end of the anchor 400 andprovides a distal facing bearing surface to resist forces (e.g.,torsional forces) generated when tensioning the suture 418 via arotational input from a set screw driver (not shown) to the set screw416 to engage the locking mechanism discussed above in relation to FIGS.8-11. The anchor driver 570 includes an axial through hole 596 to allowpassage of the set screw 416 and the set screw driver (not shown) forlocking the suture 418.

In use, for example, the anchor 400 is driven into a bone by engagingthe tabs 588 of the anchor driver 570 with the slots 462 in the anchor,as shown in FIG. 18, and rotating the anchor driver 570. A suture 418 isthreaded through the anchor 400 and passed through the clearance 592,594 outside of the driver 570, if the anchor driver 570 has not alreadybeen removed. The suture is tensioned and then the set screw 416 isdriven into the anchor 400 to lock the suture. If the anchor driver 570is still engaged with the anchor 400, the set screw 416 may be insertedthrough the axial through hole 596 in the anchor driver 570. Thetorsional force resistance provided by the anchor driver 570 engagementwith the slots 462 ensures that forces applied in locking the suture viathe set screw 416 do not affect or alter the original insertionalignment of the anchor 400.

Constructs and Operative Sequences

FIGS. 19-26 illustrate a number of examples of embodiments of thedisclosed devices in use to stabilize or reinforce ligaments and/or bonefractures. In the example of FIGS. 19-22, the exemplary devices andmethods are shown in use in a stabilization construct reinforcing thepubic symphysis 2114 to stabilize the pelvis 2100 after ananterior-posterior compression fracture 2116.

Referring to FIGS. 19 and 20, a first anchor 2120 is inserted into thepubis 2110 of a first hip bone 2104 from superior to inferior. Aflexible strand 2122 is connected to the first anchor 2120 and extendsfrom the trailing end of the first anchor. In the embodiments disclosedherein, the flexible strand may be a suture, a suture tape, a cable oranother suitable synthetic flexible strand. In the example of FIGS.19-22, the flexible strand 2122 is a braided high strength suture tape.

A second anchor 2124 such as, for example, anchors 400 or 500 discussedabove in relation to FIGS. 5-13, is inserted into the pubis 2111 of asecond hip bone 2105 from superior to inferior. The position of thesecond anchor 2124 is shown via the broken-out section view of FIG. 20,in which the second anchor 2124 is shown in cross section. A suturethreader or passer 2126 extends into the proximal or trailing end of thesecond anchor 2124, around a return feature 2128, and out the proximalor trailing end of the second anchor 2124. The flexible strand 2122 isthen threaded through a loop of the passer 2126.

Referring to FIG. 21, the passer 2126 has been withdrawn from theproximal end of the second anchor 2124 to pass the end of the flexiblestrand 2122 into the trailing end or proximal end of the second anchor2124, around the return feature 2128, and out the trailing end of thesecond anchor 2124. A tension instrument such as, for example, thetension instrument 700 disclosed in FIGS. 12-15 of U.S. patentapplication Ser. No. 15/______ entitled “COMPRESSION AND TENSIONINSTRUMENTS AND METHODS OF USE TO REINFORCE LIGAMENTS” (Attorney DocketNo. 81243.0005) and co-filed with this application on Jul. 5, 2017, maythen be used to pull the flexible strand 2122 to tension the portion ofthe flexible strand 2122 extending between the anchors 2120 and 2124 andreduce the pubic symphysis. The flexible strand 2122 may then be lockedrelative to the second anchor 2124 to maintain the reduction in anyappropriate manner including, for example, employing the tensioninstrument 700 disclosed in FIGS. 12-15 of U.S. patent application Ser.No. 15/______ entitled “COMPRESSION AND TENSION INSTRUMENTS AND METHODSOF USE TO REINFORCE LIGAMENTS” (Attorney Docket No. 81243.0005) andco-filed with this application on Jul. 5, 2017, employing the suturelocking feature discussed above in relation to FIGS. 8-11, employing theanchor driver 570 discussed above in relation to 15-18, and/or employinga set screw driver as known in the art. In this regard, a set screw maybe advanced through a central cannulation in the tension instrumentbefore a set screw driver is advanced through the central cannulation inthe tension instrument and used to thread the set screw into theinternal threads formed in the second anchor 2124 to lock the flexiblestrand 2122 relative to the second anchor at the desired tension. Thetension instrument may then be released and removed. Once the flexiblestrand is locked, the excess length of the flexible strand 2122 may betrimmed, as shown in FIG. 22.

A novel repair construct according to examples of the invention has beenshown with anchors inserted into the superior portion of the pubis tocreate a superior tension band. However, it will be understood that theanchors may be inserted in other orientations and at other locations.For example, the anchors may be inserted in the superior portion of thepubis but directed anterior to posterior or at some angle betweensuperior-inferior and anterior-posterior. Likewise, the anchors may beinserted inferior to the positions shown in the illustrative example ofFIGS. 19-22 to create an anterior tension band midway between thesuperior and inferior aspects of the pubis. Multiple bands may beapplied at various levels as needed to achieve stability.Reinforcement/repair of the sacroiliac joint may be combined with theanterior reinforcement.

While FIGS. 19-22 detail an exemplary method and associated devices forforming a fracture repair construct, similar methods and devices may beused to form ligament reinforcement constructs such as, for example,within the human ankle 100 detailed in FIGS. 2-4 above.

In another exemplary method, and with reference to FIG. 23, there may beprovided a method of at least one of reducing or stabilizing a joint.The method may include connecting 2202 a flexible strand to a firstanchor. The method may include inserting 2204 the first anchor into afirst bone. The method may include inserting 2206 a second anchor into asecond bone adjacent the first bone with a joint there between. Themethod may include routing 2208 the flexible strand into an internalpassage at the proximal end of the second anchor and around a returnfeature. The method may include tensioning 2210 the flexible strand toreduce or stabilize the joint. The method may include locking 2212 thesuture to the flexible strand. In an embodiment, the routing of theflexible strand into the internal passage at the proximal end of thesecond anchor and around the return feature may include exiting theflexible strand from the internal passage out of the proximal end of thesecond anchor. In another embodiment, the routing of the flexible strandinto the internal passage at the proximal end of the second anchor andaround the return feature may include exiting the flexible strand fromthe internal passage out of a side aperture formed through the secondanchor. In another embodiment, the routing of the flexible strand intothe internal passage at the proximal end of the second anchor and aroundthe return feature may include exiting the flexible strand from theinternal passage out of a distal end of the second anchor. Locking thesuture to the flexible strand may include a reversible configuration soas to further allow unlocking the flexible strand relative to the secondanchor. Locking the suture to the flexible strand may include applying ascrew.

FIG. 24 illustrates a first ligament reinforcement construct 2300 forreinforcing the deltoid ligament complex 124 (FIG. 3). In this constructembodiment, a suture anchor 2304 with a trailing suture 2306 has beenhas been placed in the talus 106. A second suture returning and lockinganchor 2308 such as, for example, one of anchors 400 or 500 discussedabove in relation to FIGS. 5-13 has been placed in the medial malleolusof the tibia 102. In this example, the suture 2306 trailing from theanchor 2304 is threaded through the second anchor 2308, tensioned, e.g.,manually or using a tension instrument such as, for example, tensioninstrument 700 disclosed in FIGS. 12-15 of U.S. patent application Ser.No. 15/______ entitled “COMPRESSION AND TENSION INSTRUMENTS AND METHODSOF USE TO REINFORCE LIGAMENTS” (Attorney Docket No. 81243.0005) andco-filed with this application on Jul. 5, 2017, and locked or affixedwith a set screw as discussed above in relation to FIGS. 8-11. FIG. 24also shows a separate and similar ligament reinforcement construct 2312for reinforcement of, for example, the posterior inferior tibiofibularligament (PITFL) 112 or the anterior inferior tibiofibular ligament(AITFL) 110 (FIGS. 2-4).

FIG. 25 illustrates another reinforcement construct 2400 forreinforcing, for example, the anterior talofibular ligament (ATFL) 120,the posterior talofibular ligament (PTFL) 122, or other ligaments. Inthe example of FIG. 25, two suture anchors 2402, 2404 have been placedwith suture 2406 to reinforce two separate ligaments, but a singlesuture returning and locking anchor 2408 such as, for example, theanchors 400 or 500 discussed above in relation to FIGS. 5-13, has beenplaced in the fibula 104 to secure both ligaments to a common attachmentor fixation point.

Beyond the reinforcement and repair constructs discussed above, sutureends from embodiments of the returning and locking anchors discussedabove may be used to attach other soft human or allograft tissues. FIG.26 illustrates an exemplary attachment construct 2500 in which a suturereturning and locking anchor 2504 such as, for example, one of theanchors 400 or 500 discussed above in relation to FIGS. 5-13 has beenemployed for the purpose of soft tissue repair or tendon reattachment.In this embodiment, a flexible strand such as a suture 2502 is passedthrough a tendon 2506 (e.g., Achilles tendon, rotator cuff tendon,etc.), allograft, or other soft tissue before being threaded through theanchor 2500, which is affixed with an appropriate bone 2508, tensioned,and locked, as discussed above.

Notably, any combination of ordinary suture anchors, suture returninganchors, suture locking anchors, suture returning and locking anchors,and any number of sutures per anchor may be combined to produce avariety of constructs with one-to-one or many-to-one relationships.

Although the above embodiments have been described in language that isspecific to certain structures, elements, compositions, andmethodological steps, it is to be understood that the technology definedin the appended claims is not necessarily limited to the specificstructures, elements, compositions and/or steps described. Rather, thespecific aspects and steps are described as forms of implementing theclaimed technology. Since many embodiments of the technology can bepracticed without departing from the spirit and scope of the invention,the invention resides in the claims hereinafter appended.

1-25. (canceled)
 26. A method of at least one of reducing andstabilizing a joint, the method comprising: connecting a flexible strandto a first anchor; inserting the first anchor into a first bone;inserting a second anchor into a second bone adjacent the first bonewith a joint there between; routing the flexible strand into an internalpassage at the proximal end of the second anchor and around a returnfeature; tensioning the flexible strand to reduce or stabilize thejoint; and locking the flexible strand to the second anchor.
 27. Themethod of claim 26, wherein the routing the flexible strand into theinternal passage at the proximal end of the second anchor and around thereturn feature includes exiting the flexible strand from the internalpassage out of the proximal end of the second anchor.
 28. The method ofclaim 26, wherein the routing the flexible strand into the internalpassage at the proximal end of the second anchor and around the returnfeature includes exiting the flexible strand from the internal passageout of a side aperture formed through the second anchor.
 29. The methodof claim 26, wherein the routing the flexible strand into the internalpassage at the proximal end of the second anchor and around the returnfeature includes exiting the flexible strand from the internal passageout of a distal end of the second anchor.
 30. The method of claim 26,wherein the locking the suture to the flexible strand includes areversible configuration so as to further allow unlocking the flexiblestrand relative to the second anchor.
 31. The method of claim 26,wherein the locking the suture to the flexible strand includes applyinga screw.